Journal Club: AD's Impact on Mental Health

Dr. Peter A. Lio:
Hello and welcome. I'm Dr. Peter Lio. I'm a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine in Chicago, Illinois. And I'm joined by my delightful colleague, Dr. Robert Sidbury.

Dr. Robert Sidbury:
Thanks, Peter. I'm Robert Sidbury, I'm a Professor of Pediatrics at Seattle Children's Hospital and the University of Washington School of Medicine and Chief of Dermatology here at Seattle Children's.

Dr. Peter A. Lio:
Thank you so much. And, Rob, thank you for joining me to have this discussion about a very interesting paper that I think is sort of very much something on all of our minds lately. And the paper is by Almutawa et al. This was in Curious and published June 28th, 2024. It's called The Investigation of the Impact of Atopic Dermatitis on Stress, Depression, Anxiety, and Suicidal Ideation. It's a systematic review and a meta-analysis. And I think this is something that for better or for worse, and I really do think overall it's sad that it's a thing, but it's so good and so important that we're talking about it. I think it is definitely part of the cultural zeitgeist to really think about the mental health burden that is associated with atopic dermatitis.

And the punchline for this paper, as I think you and I both know, and that's really what I want to pick your brain about, is that quote This analysis suggests that atopic dermatitis significantly impacts the psychological well-being of patients stress, depression, anxiety, and suicidal ideation are among the mental health issues commonly associated with AD. Therefore, clinicians should consider mental health evaluations for patients with AD unquote.

In your experience Rob, and I know you're focused on pediatrics where I think the stakes are even higher. Do you feel like this is an important part of thinking about the disease and counseling about the disease, and what has been your experience?

Dr. Robert Sidbury:
Yeah, thanks, Peter. These papers, this is one of several, as you know, that have come out in the last few years is sort of shown a light on this aspect of atopic dermatitis. We've been doing this a long time, you and I, we've seen the impact that this has had on kids. And we've known this is a thing, we just have and it's really simple. As you know my two least favorite words to pair together are just eczema for this reason, because we've seen for so long these kids who have this 24/7 itch, the parents ask, "What causes it?" "Oh, we're not sure." "When will it go away?" "Oh, we're not sure."

Who wouldn't be anxious and depressed under such circumstances? And so we've seen it for a long time. It is really, really important that papers like this are actually starting to put some numbers to it, both for awareness from those who may not see such a severe end of the spectrum as you and I do with atopic dermatitis, but also for carriers and for others who might support the efforts to address it going forward.

Dr. Peter A. Lio:
Oh, I love it because you're right, not only is it such an important aspect of this, but it's an insult to the injury where people sort of dismiss it sometimes. Oh, it's just as you say, "Just eczema, it's just a rash, come on." But it's so, so powerful, the effect on patients. And to me, one of the fascinating aspects is trying to figure out why. I've heard some theories, clearly if you are itchy, uncomfortable and distracted, that's going to make you miserable. If you're not sleeping well over, especially over months or years of not sleeping well, that's going to make you miserable.

But then there's this whole theory about how maybe inflammation in the body can also drive some depression symptoms, right? Brain inflammation potentially may be related. So I feel like there's multiple potential crossovers and like so many things with this disease, they can be vicious cycle forming where you're not sleeping well, so then the inflammation is worse, so then you're even more depressed so that you kind of spiral out of it.

Now when you're evaluating a patient, do you tend to bring these up directly? Do you feel like patients often just volunteer them? That's my first question for you.

Dr. Robert Sidbury:
I do. I bring them up often because many times parents, they're struggling to help their kids and they're trying to explain, "Gosh, what is this?" And oftentimes they're like, "Sometimes I think this itch is just a habit. And if we just can break that habit." And I try to make them realize that eczema is inflammation in the body, and it has incredible impacts far and wide as you've just highlighted. I point out the fact because most of the parents have already seen it because eczema often starts so early that very young infants oftentimes will start to itch when they get hungry or tired, right? Because I had eczema when I was a little kid, had them, had eczema for years.

If I get stressed, I start kind of doing that, right? There's this connection between stress and the immune system. There's a connection between the immune system and eczema. So by the transit of property, stress drives eczema and we know that. We see infants when they get hungry, start scratching, gut. When they get tired, start scratching. That's not a habit, that's inflammation, that's eczema.

Dr. Peter A. Lio:
I feel like anybody who wasn't sold on this is now sold. That was beautifully put, and that brings us to our final question. What can we do about it? Because you've alluded to the fact that it may be difficult to get some of these resources that carriers sometimes deny mental health requests. And even if you have an insurance potential, sometimes you can't get a patient in. So what do you do right now and what can we do better you think in the future? What should we be focused on?

Dr. Robert Sidbury:
Yeah, I think one thing we can do is part of why we're here today having this conversation, and why the authors of that paper published the paper is awareness. And so that's one thing, that's critical. And the second thing is just to the extent possible, we know that mental health is a crisis in this country, globally. It was pre-COVID. It certainly is post-COVID. All hands on board, right? And so every specialist, every provider, we as dermatologists see teenagers with eczema, right? How many times are they seeing their pediatrician as a 14, 15-year-old? We're the ones who are seeing them on a regular basis. Not necessarily, in some cases, yes. Not necessarily their pediatricians.

So while we're dermatologists, we're not mental health professionals, and we can't take on ownership fully of such a problem as depression or anxiety. We can recognize it. And it is our job to recognize it when it's partly driven by the condition for which we're seeing those kids. And so we can, and some will do a public health questionnaire, two item screen takes next to no time, and it's pretty darn sensitive for picking up these things. And then yes, it's upon us to then try and address that and reel in the appropriate specialists, whether it's sending them to the ER or letting the pediatrician know, but we may be saving a life. And that's really obviously something that no one wants to miss the opportunity to do.

Dr. Peter A. Lio:
Amazing. As always, thank you so much for spending time and sharing wisdom with us. This has been a delight, and thank all of you for joining us today. We hope to see everybody soon.